All posts by TheTraumaPro

Seatbelt Use By Trauma Professionals

Every trauma professional knows that seat belts save lives. Numerous studies have borne out the survival benefits of wearing them. But do those same professionals practice what they preach?

A recent study by NHTSA study showed that at least 42% of police officers killed in car crashes were not wearing their seat belts. The number of officers killed in traffic accidents in 2010 has increased by 43% over 2009 numbers. Possible reasons may be that seat belts impede the process of getting into and out of the car quickly, and that the belt may get tangled in utility and gun belts.

What about paramedics and EMTs? I couldn’t find any studies looking at this group. However, observation tells me that medics in the patient care compartment don’t always buckle up. The reason typically given is that wearing a belt may compromise patient care by limiting access to equipment, using the radio, or performing CPR. However, I think that patient care is even more limited if the EMS professional is disabled or killed in a rig crash. The patient is much more likely to survive such a crash since they are firmly strapped into place.

How can you stay safe in the back?

  • Make a commitment to your colleagues (and family) to always belt in
  • If appropriate, try to do as much of your assessment and interventions as possible before moving
  • Organize your work area so that commonly used and critical equipment is within easy reach
  • Use a cell phone for communication if the radio mic is too far away
  • If you absolutely do need to unbelt, try to do so only when the rig is stopped at a light or stop sign.

I’m interested in your comments about how common of a problem this really is. Unfortunately, I don’t think NHTSA will be doing any studies on this one.

Less Morbidity From Negative Trauma Laparotomies?

Trauma surgeons generally dread the negative laparotomy for trauma. Previous work has shown that complications occur in anywhere from 22% to 53% of cases. Those studies were usually retrospective and included patients with penetrating trauma, which may have skewed the results.

A newly published study tries to throw this common wisdom in doubt. It was a retrospective review of a prospectively maintained database of trauma admissions after blunt trauma . Patients were separated into groups who underwent immediate, delayed or no laparotomy, as well as whether they had or did not have associated injuries. Complications were tracked using an accurate and validated tracking system. The complications tracked included death, DVT, PE, infections, pulmonary issues, as well as other organ system problems.

The authors found that a negative laparotomy did not increase the complication rate, but that a delayed laparotomy did. They also noted that a Complication Impact Score (that they made up) was higher in the delay to laparotomy patients. So they believe that when clinical and imaging findings are equivocal, doing an operation to establish a diagnosis is justifiable.

My Bottom Line: This study does not look at really delayed complications like small bowel obstruction, which we see with some regularity in old trauma patients. Also, other studies have also shown that brief observation, even in patients with a bowel injury, does not increase complications significantly. Unless the potential injury that you are observing is known to have significant complications, my practice is to observe equivocal cases in order to avoid more complications down the road.

Reference: “Never be wrong”: the morbidity of negative and delayed laparotomies after blunt trauma. J Trauma 69(6): 1386-1392, 2010.

Ladder Safety In The Winter

We’ve seen a cluster of falls from the roof and/or ladders outdoors in the last week. And yes, it is very snowy in Minnesota, but ladder falls can happen to the best of us, even indoors (watch the QVC video above).

There have been five admissions to Regions Hospital’s Level I Trauma Center for adults after people fell from the roof in St. Paul since Christmas eve. All of them had serious injuries. Two died, and three sustained fractures involving elbow, spine or pelvis. I’ve seen lots of similar injuries after Christmas, when it’s time to take the lights down.

The St. Paul Department of Safety and Inspections released a statement that people should use “severe caution” while removing ice dams and snow from the roof. They go on to recommend that you “call a professional if you do not feel safe performing the work yourself.”

The problem with this statement is that the men (the majority of those injured) who climb up onto the roof do feel safe clearing the roof! They believe that this is something that they are quite capable of doing themselves. 

I recommend that we all take this statement one step further. Since everything is more hazardous outside this time of year (ice and snow on the ground and the roof), any homeowner who believes that their roof needs service should contact a professional to take care of it. If a fall occurs, you will miss some of the holiday season, and possibly permanently!

Nail Discoloration After Severe Traumatic Brain Injury (TBI)

Occasionally, patients who have had a severe brain injury but recovered relatively quickly may present with complaints of odd nail discoloration. This may involve fingernails and/or toenails. What gives?

This is actually a byproduct of repeated exams to determine the Glasgow Coma Scale score. A common way to determine the motor component is to squeeze the fingertip or toetip. I’ve seen some neurosurgeons use a pen to apply a great deal of force to the nail.

The discoloration is a resolving subungual hematoma. You may see different colors under different nails, depending on the age of the hematoma. Amaze your colleagues with your knowledge on this one!

Clinical Tip: The Flat Vena Cava in Blunt Trauma

Trauma patients who are hypotensive in the Emergency Department can only be transported to one of two places: the operating room or the morgue. With rare exception, they should never be taken outside the department (e.g. CT scan) because of the fear that they may arrest in an area that is not conducive to efficient resuscitation.

Sometimes patients are initially stable but decompensate later. Since most stable blunt trauma patients end up in CT scan, perhaps there is some telltale sign that can predict later deterioration. A recent Japanese paper looked at the “flatness” of the inferior vena cava as seen on the abdominal CT scan as a predictor of hemodynamic decompensation in the first 24 hours.

A small cohort of 114 patients was used in this prospective study. The vena cava was evaluated at the level of the renal veins. The flatness of the IVC was determined by dividing the transverse diameter by the anteroposterior (AP) diameter. A flat IVC was defined as a transverse to AP diameter ratio of more than 4:1. The ratio in normal patients was about 2:1. See the figure for details.

Patients who had a flat IVC required significantly more blood transfusions, crystalloid infusions within 2 hours of admission, and were more likely to proceed to the OR within the first 24 hours of their hospital stay.

Bottom Line: Assuming that you are only taking stable blunt trauma patients to CT, the incidental finding of a flat vena cava should increase your paranoia levels and lower your threshold for ordering blood and getting the trauma surgeons involved. 

Reference: Predictive value of a flat inferior vena cava on initial computed tomography for hemodynamic deteroration in patients with blunt torso trauma. J Trauma 69(6):1398-1402, 2010.